Creating A Diversion Prevention Team

March 2021 - Vol.18 No. 3 - Page #2
Category: Diversion Products

Among the many risks and challenges we face in the hospital setting, diversion is a danger that is always present just below the surface. The diversion of controlled substances can present a huge cost to the lives and careers of health care professionals and patients. The theft and loss of drugs also has a chilling effect on the entire hospital team, negatively impacting trust and engagement throughout a unit or department. While it is impossible to entirely prevent diversion, it is possible to create a system that will limit its frequency and increase the chances of it being detected. As such, it is important for each hospital to have a strong diversion prevention and detection program in place.

Risk Factors for Diversion

There are multiple risk factors for diversion in a hospital. Because fentanyl and other powerful controlled substances are so commonplace, health care employees may become lax in following the rules for handling these drugs. This can cause issues such as imprecise documentation, failure to physically witness a coworker’s controlled substance waste, temporary storage of medications in insecure locations, or failure to complete required paperwork. A disorganized system that lacks accountability and transparency will undermine a program’s integrity and make it clear to a potential diverter that diversion may not be detected. Breaches must be addressed so that they do not become a normal part of the culture for a unit or an entire hospital.

Holding Individuals Accountable

A culture of accountability is key to preventing diversion in a hospital. There is no substitute for individual feedback conducted in real time. For example, if a new nurse makes a controlled substance documentation error and is approached about it 24 hours later, that nurse recognizes that this hospital is not an easy place to divert medications without getting caught. Similarly, if a PRN pharmacy staff member receives a timely follow up call regarding a mistake that results in wasting a compounded controlled substance, he or she will remember to be more careful the next time. If a nurse, pharmacy employee, or anesthesia provider is struggling with an addiction, a strong system of accountability will set them up for success. If someone is facing financial hardships, the temptation to steal valuable medications will be balanced by a knowledge that the hospital’s diversion system will not allow them to avoid discovery for long. Setting clear expectations and holding people accountable is truly the best way to change behavior.

Establishing a Support System

A culture of accountability must start at the top and be reinforced by adequate systems and processes. Open communication between pharmacy and hospital administration is an important way for pharmacy to gain administration’s support for investing in diversion-prevention resources. Pharmacy leaders can build rapport with the hospital administration by sharing facts and statistics, as well as by assessing administration’s prior experience. From here, pharmacy leaders can work to find a willing champion and begin a partnership against diversion.

Often the partnership works best between the pharmacy and those who have a more natural understanding of diversion due to their background and experiences, such as nurses, operating room leaders, and physicians. Nevertheless, many administrators with a non-clinical background also have a deep understanding of diversion and appreciation for the risks. A robust medication diversion program will include input from a diverse group of leaders who have oversight over all areas of the hospital.

Creating a Diversion Prevention Team

One of the key elements of a successful diversion prevention program is the creation of a team to manage it. The American Society of Health System Pharmacists (ASHP) Guidelines on Preventing Diversion of Controlled Substances highlights many key aspects of a Controlled Substance Diversion Prevention Program (CSDPP). The first recommendation is that “the organization establishes an interdisciplinary CSDPP committee to provide leadership and direction for developing policies and procedures for overseeing the CSDPP.”1 A Diversion Prevention Team (DPT) should include clinical leaders as well as non-clinical leaders. Each hospital will have different organizational structures, but ideally, the team will include the following:

  • Chief Executive Officer (CEO): According to the Drug Enforcement Administration (DEA), the CEO is the registrant who is ultimately responsible for all controlled substances at the hospital. The CEO is also the individual who sets priorities for the organization and who can direct each discipline (eg, nursing, pharmacy, physicians) to follow the controlled substances policies. Although this person’s time is incredibly valuable, diversion is such an important topic that it warrants their regular attendance on the committee.
  • Pharmacy: Pharmacists and technicians naturally play a key role, due to their central role in the distribution and oversight of controlled substances. They will conduct many of the audits and perform much of the oversight. However, it should be emphasized that the committee’s work is a shared responsibility, and the meetings should not be limited to pharmacy leaders reporting what they have identified. It is pharmacy’s role to build teamwork, ownership, and shared purpose among all members of the committee.
  • Chief Financial Officer (CFO): While there may be a huge financial impact when diversion occurs, either in fines or litigation, diversion prevention is also costly in terms of system purchases and labor. For example, a comprehensive program requires investments in automated dispensing cabinets (ADCs), cameras, analytics software, and hiring the right people to support the program. All of these items require the CFO’s support for approval. The DPT meetings are a place where the CFO can ask questions and learn about the true value of these investments.
  • Physicians and Anesthesiologists: Physician leadership and support is crucial for the success of any initiative in the hospital, and anesthesia providers practice in an area where controlled substances are readily accessible and plentiful. Engagement with physicians and anesthesia providers ensures that controlled substance management is truly interdisciplinary.
  • Nursing: Strong engagement among all layers of nursing leadership, from the chief nursing officer down to nurse managers and frontline nurses, is crucial to ensuring the committee’s effectiveness. The voices of the frontline nurses help the team understand the obstacles that prevent best practices and flawless documentation. The committee should serve as a forum where key issues are identified and efforts focused on how to solve these problems.
  • Security: The security team’s involvement is vital to resolving suspected diversion as well as supporting prevention activities. Their skillset and background are helpful for investigations, setting up camera systems, and interacting with local law enforcement.
  • Human Resources: Human Resources professionals are able to guide the other leaders in creating policies that are fair and follow all employment laws. They can assist with employee interviews during diversion cases and can guide leaders in setting up corrective action plans to help hospital employees follow medication policies or be held accountable.
  • Compliance/Risk Management: Compliance and risk management teams are experts in aspects of health care management that are outside most leaders’ daily duties. They can clarify how diversion is putting the hospital at risk, and how best to mitigate that risk.

ASHP also recommends that the following individuals be involved:

  • Legal: Policies about drug screenings, employee termination, and anything related to potential patient harm will need input from the hospital’s legal counsel.
  • Communications: Communications professionals are skilled in crafting educational and marketing materials to help disseminate information about the diversion prevention program. They also may need to get involved if a diversion event attracts media coverage.
  • Information Technology: More and more, the diversion prevention program depends on well-integrated information technology, including the electronic health record, ADCs, and analytics software. While IT may not need to attend all of the meetings, their contribution to the diversion prevention team is nonetheless important.

This may seem like an unusually broad group of leaders, but our experience at HCA Healthcare has shown that there is great value in bringing this group together. Each member of a hospital leadership team brings a unique background, skillset, and perspective. It is helpful for all members of this leadership team, clinical and non-clinical, to come to the table to build a strong system. The HCA Healthcare enterprise policy states that each hospital must meet monthly with their Medication Diversion Team (MDT), with certain required attendees and a consistent agenda. This framework promotes engagement of key leaders with the diversion prevention program, and it ensures that the information is shared widely to all stakeholders. Each month certain employees are audited, some randomly and some based on risk assessment software, and the results of those audits are discussed at the meeting. The MDT agenda items also include discussion of diversion risk rounds, follow up from the previous meeting, various quality assurance metrics to ensure monitoring processes are being followed, and discussion of any concerning issues that were uncovered since the previous month. While this approach is predicated on a significant investment of time, both in preparation for the meeting and in the meeting itself, it pays dividends because of the broad alignment that it creates within the entire leadership team.

The ASHP guidelines spells out further tasks to be fulfilled by the DPT. These include:

  • Developing policies and procedures
  • Providing ongoing reviews of compliance with controlled substance
  • Reviewing audits and action plans
  • Interfacing with other organizational compliance programs
  • Conducting diversion risk rounds and conducting systematic analyses to identify areas of vulnerability
  • Responding to diversion events
  • Reviewing diversion incidents and diversion trends to identify system
  • Providing oversight to ensure compliance with diversion policies and state and federal law
  • Collaborating with outside stakeholders

Diversion Response

In 2019, Kimberly New, JD, BSN, RN, discussed the creation of a diversion response policy, noting that the real-time response to an actual or suspected diversion should include a team of people who can brainstorm and make sure that all necessary actions have been completed without delay.2 There are specific DEA and state requirements regarding reporting, HR policies to follow, and multiple risks with an approach that is overly aggressive or too passive. A solid Diversion Response Policy, such as the response outlined by New, is an invaluable guide during an emotional and unclear situation.2

A multidisciplinary team will be most effective in implementing the checklist and asking the right questions to make sure all of the necessary actions are taken. The Diversion Response Team can be a predetermined subset of the existing DPT, and the actions of that small response team can be discussed with the broader group at the next regularly scheduled meeting. The time spent discussing specific cases also helps to dispel the “not in my backyard” phenomenon. If skeptical members of the leadership team believe the policies and audits may be excessive or unreasonable, their inclusion in the discussions around specific suspicious events can help demonstrate the value of these policies.


A controlled substance diversion prevention and detection program can thrive when frontline accountability is combined with the support of an interdisciplinary oversight committee. A regularly scheduled meeting, ideally monthly, compels the group to come together to talk about diversion and ensure that important monitoring functions are being completed. That consistent time is a valuable investment in education, shared understanding, communication, and relationship building. It takes a team to be successful in other areas of health care, and this is especially true for diversion prevention and detection. A diversion prevention team plays an important role in this critical work and should be a part of every hospital’s overall plan.

Disclaimer: This research was supported (in whole or in part) by HCA Healthcare and/or an HCA Healthcare affiliated entity. The views expressed in this publication represent those of the author and do not necessarily represent the official views of HCA Healthcare or any of its affiliated entities.


  1. Brummond PW, Chen DF, Churchill WW, et al. ASHP Guidelines on Preventing Diversion of Controlled Substances. Am J Health Syst Pharm. 2017;74(5)325-348.
  2. New K. Establish a Diversion Response Policy. Pharm Purch & Prod. 2019;16(5). Accessed January 8, 2021.

Nathan Hanson, PharmD, MS, BCPS, is the division director of pharmacy operations for the HealthTrust Purchasing Group. Nathan holds a doctor of pharmacy degree from Drake University, and a master’s degree in pharmacy administration from the University of Kansas. He completed his Health System Pharmacy Administration PGY1/PGY2 residency at the University of Kansas Health System. In his current role, Nathan serves the 7 Kansas City hospitals in the HCA MidAmerica Division in the areas of controlled substance management, sterile compounding, Joint Commission readiness, pharmacy distribution, and leadership development.

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